Ruminations by a non-academic general surgeon from the heart of the rust belt.

Saturday, December 27, 2008

Mandated Health Insurance

President-elect Obama has his work cut out for him. A recent poll from Consumer Watchdog suggests that the majority of Americans are opposed to any federal proposals that would mandate that each citizen demonstrate proof of health insurance. Lack of mandated coverage would then result in tax penalties or other fines.

Frankly, this finding is outrageous, but all too illustrative of a "gimme something for nothing" tendency we see in this country. Currently, about 16% of our entire GDP is spent on health care. That's a lot of dough. Opting out of health insurance places an enormous burden on those who play by the rules. It's a violation of the social contract. It's certainly unethical and one could make an argument that there is something almost criminal about such a choice. Isn't it a form of stealing? People didn't blink an eye when laws were passed ten years ago mandating car insurance. It's easy and not all that expensive. Shop online. Choose a cheap collision-only plan, if that's all you can afford. But when it comes to insuring our health; how dare you force me to buy coverage? I'm not sick! I haven't been to a doctor in years!

Obviously, I'm glossing over pertinent issues such as the cost of purchasing individual health insurance independently of your employer. And the problem of insuring unhealthy people. And the lack of choice individuals have if they decide to strike out on their own (as opposed to the car insurance example where you can browse Progressive, GEICO, State Farm etc online until you find the best deal). But the results from the (admittedly a limited sample) poll are disturbing.

If we can't be more self sufficient and act in a manner that is most conducive to the benefit of the greater whole, we just give more ammunition to proponents of single payor, federally directed, monolithic "National Healthcare" plans. You see, they argue, Americans can't be trusted to do the right thing. Unless we place all the power in the hands of a giant federal bureaucracy we will continue to have 50 million uninsured and exponentially rising health care costs! With nationalized coverage, there will be no need for "mandates"! Everything will be paid for. By wealthier Americans! No worries!

Turning our health care system in a giant version of the VA or a County Hospital with physician remuneration via a hypertrophied Medicare/Medicaid is surely not the corrective antidote. Individual choice still matters. Foisting the responsibility onto our populace is not necessarily a bad thing. There have to be consequences for those who choose not to fulfill that repsonsibility. Once health insurance is mandated, we can manipulate things to make some form of coverage available to all Americans. But it first has to be ingrained in the societal conscience that going through life (irrespective of how 'healthy' you are) without health insurance is unacceptable....

12 comments:

Anonymous
said...

I'm with you, but where are all of the FPs going to come from? If I remember correctly, that was one of the lessons learned from the MA mandate: it's hard to force people to have health care if there aren't enough primary care docs to go around. There's going to have to be a pretty big carrot for current and future med. students to go into primary care, and I envision that carrot being an even harder political sell than mandating the cheap collision-only plan.

You are living in a tunnel of how you wish things could be, and how you assume they are, regardless of the facts of the issue. Show me a health plan that even comes close to car ins. and I will show you people lined up to buy into it. But when you get quoted prices like $1,100.00 - $1,400.00 per month, per person, for health ins. (not even a good plan) you are dreaming when you say it is unethical and should be illegal not to have it. It is neither of those things. What it is, is non-doable. That's the bottom line. Health ins. in this country is not financially an option for a very large percentage of people.

When they don't pay a hospital bill is that also criminal and unethical? It should be illegal, and it IS certainly unethical, to receive a bill for $25,000.00 for a couple of hours ER work up.

Two sides of the coin indeed. No doubt health insurance needs to be more affordable (which may involve rationing of care and a two or even three tiered system) but to simply refuse to acknowledge one's own responsibility for the financial provision of said care is truly reprehensible.

I am struck by the poll's implication that the majority of Americans don't feel an obligation to contribute to the health insurance safety net; that somehow, someway, when they get sick someone else (read: the government) will be there to prop them up.

My point in this post is to emphasize the need to change this mindset of unaccountability. For health care reform, innumerable changes need to be made (making primary care more desirable, increasing availability of affordable plans, etc) but there needs to be a fundamental overhauling of the way most Americans understand their own responsibility for how these changes are going to be implemented....

40% of people in the poll are "strongly opposed" to any form of mandated insurance. Maybe that number will decrease if we can make health insurance more affordable, but nevertheless that's a staggering number of individuals who presume to benefit from the contributions and labors of others...

Sorry, but as someone who already has "mandated" insurance, i.e. Medicare, no thanks. Would I buy better insurance if I could? Sure, but 1) it's unaffordable (try $500 for supplemental and $1200 for replacement but oh, I am uninsurable because I have a chronic illness) and 2) the law says it would have to be secondary to Medicare if I did.

What you suggest is simply not in touch with reality. Should we all be responsible? Yep. But you cannot mandate "responsibility". The analogy of auto insurance fails. Why? Because even in Ohio, with the law as it is, at least 10 to 15% of drivers are uninsured at any time and the rest of us pay for them. (In states such as California with a high percentage of illegal immigrants the percentage sometimes tops 30%).

So, unless you are going to add medical insurance to the annual income tax bill and deduct it from paychecks, it won't happen for even 90$ of the population.

As for not paying hospital and doctor bills... do you think that the bills go unpaid because I or others in my situation don't want to pay them? Nonsense. If it is down to eating and paying rent or paying that 20% Medicare didn't what do you think I should do? Sorry, try living on what I do and make that same decision. Get real.

Don't know the phrasing of the poll, but my personal misgivings about such a plan are that I neither want nor need the kind of health insurance likely to be mandated (as was done in MA).

I'm quite content to pay out of pocket a significant amount of my healthcare bill in any given year before insurance kicks in (i.e. high deductible).

Even as a guy who's supposed to get MRIs every year or two, with an occasional specialist visit or two, and the eventual,almost certainly unavoidable threat of multiple back surgeries, I fare better paying my own way for the first several thousand dollars per year.

But that's just me.

Like you said, I think it'd be different if they actually compete for our business, and if we hold the reigns in controlling the size of our premiums to a degree just like in car insurance.

Whatever.

Overall, I do agree with your central contention about the violation of the social contract by nonpayers.

Miami, I disagree with you. Insurance products are among the most highly regulated in the U.S. In order for rates to be adjusted, they must apply to the state department of insurance, giving good reason (in this case, it must be actuarially sound). A mandate on purchasing health insurance can work, and it can be locally tailored to 50 different jurisdictions reflecting different risks, as long as everyone participates. Otherwise, you don't spread the risk. I do agree that we don't want politicians setting benefit levels into law. There are too many constituencies to please.

Mandatory Health Insurance? good way to make everyones rates go up, no way you can charge the Obese Hypertensive HIV+ Schizophrenic COPDer Diabetic enough to break even...and they'll make it up somewhere...of course if your employer pays for it Who Cares!?!?! Its Free, just like those Sweet N Lows I've been hoarding at AA meetings for the last 20 years....

I don't know J. The fact that the system is already highly regulated and is also a disaster doesn't bode well for a future with even greater regulation under a mandate system. Either these companies will be forced to cover a host of politically sensitive conditions at greater cost to everyone with no ability to avoid the rate hikes or we'll see a situation in which rates will be held artificially low and we'll bankrupt the companies. I guess a third option is subsidizing the companies with tax dollars or fed funny money, so that we can create executive profits out of hidden taxes or future inflation.

Miami, it's cost shifting. The insured are paying for the uninsured, and the hospitals use a tax writeoff for the charity care or get increased Disproportionate Share (DSH) payments. The way self-insured plans do it, everyone pays into a big pot of money and that money pays the claims. Is it possible to do it on a state-by-state level? Maybe, but that might mean lower reimbursement rates for lower premiums, but you don't have to worry about collections anymore.

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